Ken Grauer, MD

APRIL 26, 2024

IMPRESSION: In this patient who presents with severe, new-onset CP — today's ECG is diagnostic of an extensive, ongoing antero-lateral STEMI. ECG Blog #193 — Reviews the basics for predicting the " culprit " artery ( as well as reviewing why the term "STEMI" — should be replaced by "OMI" = O cclusion-based MI ).

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Blog STEMI Aneurysm AFIB 147

Dr. Smith's ECG Blog

JULY 18, 2014

Thus, this is BOTH an anterior and inferior STEMI in the setting of RBBB. How old is this antero-inferior STEMI? Although acute anterior STEMI frequently has narrow QR-waves within one hour of onset (1. the presence of such well developed, wide, anterior Q-wave suggests completed transmural STEMI. Could it be acute (vs.

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STEMI Pericarditis Myocardial Infarction Cardiogenic Shock 52

Dr. Smith's ECG Blog

NOVEMBER 26, 2015

These elevations meet STEMI criteria ( ≥ 1mm in 2 contiguous leads). However, old MI w/aneurysm morphology (persistent ST-Elevation) can look just like this. While this may be change that is reciprocal to an Acute/Subacute Inferior STEMI, the problem is that LV aneurysm may also manifest with this reciprocal change.

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Chest Pain Aneurysm STEMI Document 52

Dr. Smith's ECG Blog

OCTOBER 26, 2011

Echo on the day after admission showed EF of 30-35% and antero-apical wall akinesis with an LV thrombus [these frequently form in complete or near complete (no early reperfusion) anterior STEMI because of akinesis/stasis] 2 more days later, this was recorded: ST elevation is still present. Cath showed a 95% LAD with flow. This was recorded 2.5

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STEMI Chest Pain Myocardial Infarction Angioplasty 52

Dr. Smith's ECG Blog

JANUARY 28, 2023

Only very slight STE which does not meet STEMI criteria at this time. I am immediately worried that this OMI will not be understood, for many reasons including lack of sufficient STE for STEMI criteria, as well as the common misunderstanding of "no reciprocal findings" which is very common with this particular pattern. 6.5 = 0.38.

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STEMI Chest Pain Stent Stents 52

Dr. Smith's ECG Blog

DECEMBER 29, 2015

would require the ST/S ratio to be 25% for diagnosis of STEMI in LVH. The physician was concerned about STEMI, but also worried that she was overreacting, with the potential that LVH was producing a "STEMI-mimic." Can you diagnose an ACO (STEMI) when you also have LVH? Is LVH like left ventricular aneurysm?

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STEMI Myocardial Infarction Chest Pain Aneurysm 40

Dr. Smith's ECG Blog

OCTOBER 17, 2024

The prehospital and ED computer interpretation was inferior STEMI: There’s normal sinus rhythm, first degree AV block and RBBB, normal axis and normal voltages. The paramedic notes called STEMI into question: “EMS disagree with monitor for STEMI callout. Vitals were normal except for oxygen saturation of 94%. Vitals were normal.

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Chest Pain STEMI Pulmonary Embolism 74

Dr. Smith's ECG Blog

OCTOBER 15, 2024

A prehospital “STEMI” activation was called on a 75 year old male ( Patient 1 ) with a history of hyperlipidemia and LAD and Cx OMI with stent placement. The EKG is diagnostic of acute inferior, posterior, and lateral OMI superimposed on “LV aneurysm” morphology. The prehospital ECG of Patient #1 — showed an obvious acute STEMI.

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Chest Pain STEMI Echocardiogram Stent 117

Dr. Smith's ECG Blog

MAY 18, 2011

Diagnosis: There are Q-waves, ST elevation, and hyperacute T-waves in V2 and V3, diagnostic of acute LAD occlusion (STEMI). Sometimes you will find an obvious STEMI. This may resolve over a couple weeks; if it does not, then he is at high risk of developing an LV aneurysm, or diastolic dysfunction of the anterior wall.

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Chest Pain Myocardial Infarction STEMI Aneurysm 52

ECG Cases

OCTOBER 13, 2020

How can one distinguish MI vs LV aneurysm on ECG? 9 patients presented with potentially ischemic symptoms and Q-waves. Which had Occlusion MI? What is the differential diagnosis of Q-waves? The post ECG Cases 14: Q-wave and Occlusion MI appeared first on Emergency Medicine Cases.

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Aneurysm STEMI 52

Dr. Smith's ECG Blog

JULY 19, 2019

STE occurs primarily in viable ischemic myocardium; persistent STE after completed infarction is ominous and portends development of an aneurysm. But it does not meet STEMI criteria and it was not initially recognized. Whereas most STEMI(-) OMI is acute, this one might have had STE at its onset, or earlier in its course.

Chest Pain 52

Chest Pain STEMI Aneurysm Pericarditis 52

Dr. Smith's ECG Blog

OCTOBER 20, 2013

Note that they finally have laid to rest the new or presumably new LBBB as a criteria for STEMI. Note that they finally have laid to rest the new or presumably new LBBB as a criteria for STEMI. Also note that they allow ST depression c/w posterior MI to be a STEMI equivalent. What is the utility of a head CT in cardiac arrest?

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Cardiac Arrest STEMI Hemorrhage Hospital 52

Dr. Smith's ECG Blog

FEBRUARY 29, 2016

This may be permanent and may be associated with echocardiographic dyskinesis (aneurysm). LV aneurysm is common in completed, full thickness (transmural) MI, which is what we have here. It is uncommon in the age of reperfusion therapy, as most STEMI get treated reasonably early, before transmural infarct.

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Aneurysm Ischemia Embolism STEMI 52

Dr. Smith's ECG Blog

SEPTEMBER 20, 2018

There is a very small amount of STE in some of the anterior, lateral, and inferior leads which do NOT meet STEMI criteria. The case was reviewed by all parties, and it was stated correctly that the ECG does not meet the STEMI criteria. The STEMI vs. NSTEMI paradigm is not the best way to decide who needs emergent reperfusion therapy.

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Chest Pain STEMI Cardiac Arrest Aneurysm 52

Dr. Smith's ECG Blog

JULY 31, 2013

We have found in our study comparing inferior STEMI (manuscript in preparation) to inferior early repol several distinguishing characteristics. A coronary aneurysm was found. And young women have worse outcomes than other groups with STEMI because of the tendency to say, "Nah, couldn't be!" A second troponin returned at 1.71

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Chest Pain Aneurysm STEMI Ischemia 52

Dr. Smith's ECG Blog

JULY 26, 2023

But the well-formed Q-wave and the presence of a normal T-wave in inferior leads led me to believe this was Old Inferior MI with persistent ST Elevation, otherwise known as inferior LV aneurysm. Anterior LV aneurysm is much easier to recognize because the Q-wave is usually a QS-wave (no R-wave at all), in at least one lead.

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Aneurysm Chest Pain STEMI Bradycardia 52

Dr. Smith's ECG Blog

MARCH 9, 2023

Barely any STE, and thus not meeting STEMI criteria. Annals of Emergency Medicine Cardiology was called to evaluate the patient immediately for emergent cath, but they stated that the ECG did not meet STEMI criteria and elected to wait for further information before proceeding with cath. He was given 6mg IV morphine for ongoing pain.

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Chest Pain STEMI Myocardial Infarction Blog 52

Dr. Smith's ECG Blog

JANUARY 9, 2023

50% of LAD STEMIs do not have reciprocal findings in inferior leads, and many LAD OMIs instead have STE and/or HATWs in inferior leads instead. The ECG easily meets STEMI criteria in all leads V2-V6, as well. Repeat CT angio chest (not CT coronary, unclear what protocol) showed possible LAD aneurysm and thrombus. Pericarditis?

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Chest Pain Aneurysm STEMI Thrombosis 52

Dr. Smith's ECG Blog

SEPTEMBER 16, 2015

It may be difficult to read STEMI in the setting of RBBB. There is, however, a long QT also, with abnormal T-waves, but this is not STEMI. An elderly patient with a ruptured abdominal aortic aneurysm: Formal ECG Interpretation (final read in the chart!) : "Inferior ST elevation, lead III, with reciprocal ST depression in aVL."

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STEMI Chest Pain Cardiac Arrest Stent 40

Dr. Smith's ECG Blog

JULY 3, 2018

Despite ongoing chest discomfort and an uptrending troponin, he never meets STEMI criteria. The full thickness infarction with LV aneurysm morphology places him at a higher risk for short and long term complications (e.g., Free wall rupture, VSD, Dresslers Syndrome, chronic CHF, anatomic LV aneurysm, LV thrombus, stroke, etc).

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Pericarditis Chest Pain Stent Stents 52

Dr. Smith's ECG Blog

APRIL 3, 2019

Not quite a STEMI, but same effect.) There is ST elevation in V2-V4 that does not quite meet "STEMI criteria." You might think it is "Old MI with persistent ST Elevation" (otherwise known as "LV aneurysm" morphology.") Is this a transient STEMI? When Q-waves have developed, it cannot be assumed to be a transient STEMI.

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STEMI Chest Pain Ischemia Aneurysm 40

Dr. Smith's ECG Blog

APRIL 17, 2023

The Queen of Hearts correctly says: Smith : Why is this ECG which manifests so much ST Elevation NOT a STEMI (even if it were a 60 year old with chest pain)? Physician interpretation: "No STEMI." Physician: "No STEMI." Cardiologist interpretation: "Technically does not meet STEMI criteria but concerning for ischemia."

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Chest Pain STEMI Document Ischemia 52

Dr. Smith's ECG Blog

JANUARY 16, 2020

Also a h/o LV aneurysm with thrombus, on anticoagulation, as well as a dual chamber pacemaker. Aneurysm of the mid-portion of the lateral and inferolateral wall. Marked acute STEMI changes in no less than 4 lateral leads. They called 911. On arrival, the BP was 60/30. See the outpouching at the bottom of the image.

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Aneurysm Heart Disease Stent Stents 40

Dr. Smith's ECG Blog

MAY 19, 2020

This is a troponin I level that is almost exclusively seen in STEMI. The patient's heart had significant recovery: Echo : Estimated LVEF 32%, apical wall motion abnormality with diastolic distortion (LV aneurysm), suggestive of old MI. So this is either a case of MINOCA, or a case of Type II STEMI. Troponin I rose to 44.1

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Defibrillator Circulation Plaque Cardiac Arrest 52

Dr. Smith's ECG Blog

AUGUST 13, 2020

Old MI with persistent ST Elevation (LV aneurysm morphology) can look like acute MI 2. Not all anterior LV aneurysm has a QS-wave. Dyspnea, Right Bundle Branch block, and ST elevation Here are two more cases where the differential diagnosis is acute OMI vs. LV aneurysm: Is this acute STEMI? LV Aneurysm?

Tachycardia 52

Tachycardia AFIB Cardiogenic Shock Myocardial Infarction 52

Dr. Smith's ECG Blog

MARCH 11, 2016

cm diameter in the apex The presence of thrombus led the clinicians to state that this was a "late presentation STEMI." It does take some time for thrombus to form, but the EKG and the troponin profile show that this was NOT a late presentation STEMI. Perhaps she will not develop an LV aneurysm. LV Thrombus , 1.5

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Myocardial Infarction Pericarditis STEMI Angina 52

Dr. Smith's ECG Blog

MARCH 11, 2019

The only time you see this without ischemia is when there is an abnormal QRS, such as LVH, LBBB, LV aneurysm (old MI with persistent STE) or WPW." There is upsloping ST elevation in III, with reciprocal ST depression in aVL. You do NOT see this in normal variant STE, nor in pericarditis.

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Chest Pain Ischemia Aneurysm Myocardial Infarction 52

Dr. Smith's ECG Blog

JANUARY 6, 2023

Immediate and early percutaneous coronary intervention in very high-risk and high-risk Non-STEMI patients. A CT was completed to rule out dissection, PE, or aneurysm, and this was unremarkable. Clin Cardiol 2022; [link] Labs included: hsTnI 156 ng/L, Hb 12 g/dL, WBC 12x10^9/L, Cr. mg/dL, K 3.5

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction ICU 52

Dr. Smith's ECG Blog

DECEMBER 18, 2022

Post-myocardial infarction (MI) ventricular septal defects are frequently seen in mid-anteroseptal and apical septal segments, whereas apex and the basal inferior segment are prone to aneurysm formation. These being said, the most important thing in this clinical situation is to diagnose OMI, whatever you call it.

Myocardial Infarction 40

Myocardial Infarction Chest Pain Blog Echocardiogram 40

Dr. Smith's ECG Blog

MAY 21, 2012

It looks like anterior LV aneurysm. In acute STEMI, the T-wave is large, whereas in LV aneurysm , the T-wave is not so large. If greater than or equal to 0.22 , then acute anterior STEMI. correlates with anterior STEMI) Rule 2. correlates with anterior STEMI). correlates with anterior STEMI).

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STEMI Chest Pain Aneurysm Biomarkers 40

Dr. Smith's ECG Blog

JANUARY 2, 2023

It is clearly not a STEMI and is therefore a Non-STEMI or NSTEMI.) This shows that the term Non-STEMI is useless, as Non-STEMI can be either OMI or NOMI. This troponin value makes the diagnosis of acute MI almost certain, but this troponin by no means tells you if it is OMI or Non-OMI (NOMI).

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STEMI Chest Pain Blog Aneurysm 52

Ken Grauer, MD

DECEMBER 21, 2024

iv ) The findings in Figure-4 could reflect LV aneurysm. This may account for the anterior ST elevation seen in today's case ( BLUE arrows in leads V1,V2,V3 ). C onclusion: As I contemplated today's tracing that I initially interpreted without the benefit of any history I thought any of the above diagnostic possibilities might be present.

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Blog Aneurysm STEMI Ischemia 98

ECG Cases

FEBRUARY 17, 2025

Jesse McLaren explains how STEMI criteria can be false positive with large scale QRS and proportional ST elevation, or false negative with low/normal scale QRS and disproportionate ST elevation and hyperacute T waves, and that rules for subtle occlusion using proportionality can help differentiate LBBB with or without Occlusion MI, or LV aneurysm vs (..)

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STEMI Aneurysm 78

Dr. Smith's ECG Blog

MARCH 3, 2025

There are no Q-waves to suggest old inferior MI, or inferior aneurysm as the etiology of the ST Elevation. Supply-demand mismatch can cause ST Elevation (Type 2 STEMI). Also see these posts of Type II STEMI. Truly, the Marquette 12 SL algorithm correctly identifies this STEMI. See reference and discussion below.

Tachycardia 74

Tachycardia Pulmonary Chest Pain Stenosis 74

Dr. Smith's ECG Blog

FEBRUARY 26, 2025

When there are QS-waves, one should always think about LV aneurysm, but ST to QRS ratio and T-wave to QRS ratio are far too large and not compatible with left ventricular aneurysm. 50% of LAD STEMI have Q-waves by one hour. There is some R wave in the lateral precordial leads. Leads V3 and V4 both have 6mm ST elevation.

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Chest Pain Pericarditis Myocardial Infarction Dementia 90

Dr. Smith's ECG Blog

DECEMBER 3, 2024

His initial high sensitivity troponin I returned at 1300 ng/L and given that his cardiac workup was otherwise unremarkable, a CT was obtained to evaluate for pulmonary embolism and aortic aneurysm or dissection but this too was unrevealing. Another EKG was also obtained. ECG at time 82 minutes: What do you think?

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Catheterization Laboratory STEMI Blog Ischemia 111

Dr. Smith's ECG Blog

NOVEMBER 29, 2024

It is consistent with an inferior LV aneurysm. Queen : she saw no OMI (no "STEMI Equivalent") either Continued : Now, she says she was walking to the bathroom when she experienced acute onset substernal chest pressure radiating into her neck and left arm. It is almost certainly not acute.

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Chest Pain Hospital Anatomy Aneurysm 67